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Parents, Open Enrollment Is Time to Check Provider Networks

The last thing any parent of a sick child wants to learn is that the doctor or hospital best able to help is not in your health plan network. Open enrollment is an opportunity for parents to make sure they select a plan ensuring adequate access to pediatricians, pediatric specialists and children’s hospitals.

Even within the same plan, coverage networks can change every year and sometimes during the year. So, while cost sharing (deductibles, co-payments and co-insurance) are extremely important factors in choosing a plan, the plan’s provider network (“network adequacy”) will determine whether you will have timely access to the most appropriate and qualified health care providers, specialists and facilities your child may need.

As the cost of health care continues to rise, one of the ways health insurance companies control costs is to shrink provider networks and exclude certain physicians and health care facilities. For parents, this could mean limited access to pediatric specialists when your child most needs them. It also could mean you might have to pay more out-of-pocket to access those important pediatric specialists. Therefore, it’s important to check the networks of each plan you consider as they can vary widely.

Most commercial health care plans (employer-based for example) are regulated by states, which set minimum standards for network adequacy. On the whole, these standards lack specifics regarding how sufficient their networks are to meet the needs of children. This puts the burden on parents to do their research before selecting a plan.

Millions of families are now gaining coverage through Qualified Health Plans (QHPs), the private health care plans offered via the Affordable Care Act’s marketplace. Unfortunately some of these plans are not providing adequate access to pediatric providers and facilities. In a 2015 survey of children’s hospitals, 75 percent of responding hospitals reported being excluded by one or more Qualified Health Plan in their state marketplace for the 2015 coverage year. This situation could change as additional federal and state rules are put into effect, but not in time for this year’s open enrollment that ends on Jan. 1, 2016.

States must set some minimal network adequacy standards for publicly funded health care plans like Medicaid and the Children’s Health Insurance Program (CHIP). In addition, these public programs have a long history of covering children, and CHIP was specifically designed to cover children. As a result, the plans tend to have provider networks that include the providers that kids need, especially kids with complex medical conditions who rely on highly trained pediatric specialists practicing in children’s hospitals.

Children’s health care needs are different from adults’. For example, there are a broad range of childhood illnesses, diseases and disabilities that are rarely, if ever, seen in adults. Because children come in all sizes, from infants to teens, they need access to facilities with equipment that fits — from preemie diapers and tiny blood pressure cuffs to all sizes of needles and breathing tubes. And because children may be too young to talk or have a hard time expressing themselves, health care providers need to have special communications skills to work with children. Children need to be cared for by health care providers who understand these important differences. It simply takes more time and resources to adequately address the health care needs of kids.

Nationwide, there are far fewer pediatricians, pediatric specialists and children’s hospitals than there are adult providers. Excluding these health care providers from health plan networks can have devastating consequences for you and your child, if he or she faces a health challenge that requires the care of a pediatric specialist. Open enrollment is the ideal time to compare health care plans to ensure you select one with a network that includes the pediatric providers best trained and equipped to care for your children, including a children’s hospital.